Neurosurgeons often have to cope with intraventricular hemorrhage (IVH) and hydrocephalic retention, as a frequent complication of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH). Whether or not surgical treatment is indicated is under controversial discussion, including very different trends all over the world. In general, the clinical outcome after severe SAH or ICH with IVH is reported to be poor.

Conventional surgical treatment consists of ventricular drainage, with or without fibrinolysis or surgical evacuation. The therapy of this particular obstructive hydrocephalus is often very challenging, with persistent clotting of the external ventricular drains, and their repeated exchanges. Even placement of the first ventricular drain in a blood-clot filled ventricle is sometimes difficult. How could an endoscopic intraventricular procedure, where clear sight is mandatory, be helpful? Browsing the literature, neuroendoscopic experience in IVH is rare. Longatti et al. looked back over a period of seven years with neuroendoscopic management of IVH in 13 patients. [1] A flexible endoscope was used for this procedure; the effect of the evaluation and clinical outcome were rated by using the Graeb score, ventriculocranial ratio, and Glasgow Outcome Scale. Substantial removal of intraventricular blood was possible in all patients. The Graeb score and ventriculocranial ratio decreased significantly. The favorable outcome (GOS 3-5) was high, 61.5%. Even though, this was a small case series, the results reassured neuroendoscopists, notably, that a rigid endoscope could provide a superior intraventricular view, with better applicability. Chen et al. compared the efficacy of endoscopic surgery for the evacuation of IVH with that of external ventricular drainage (EVD) surgery. [2] Forty-eight patients with IVH caused by thalamic hemorrhage were randomly divided into an EVD group and an endoscopic surgery group. The authors found no significant difference between the two groups for outcome and mortality rate. However, the Intensive Care Unit (ICU) stay was shorter, and the need for shunting was significantly lower in the endoscopic surgery group. Thus, there were studies that pointed to an advantage with the application of endoscopy. Also, there is a current debate whether surgical treatment with ventricular drainage can be more effective in combination with intraventricular fibrinolysis. Nieuwkamp et al. performed, in 2000, a systematic review of the literature and found that treatment combined with fibrinolytics might improve the outcome of patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. [3] A randomized study is ongoing. Our group has gained experience with 34 endoscopic procedures, which were performed for hemorrhage-related obstructive hydrocephalus. [4] In this study, blood clot removal was only applied to gain access to the floor of the third ventricle, to perform endoscopic third ventriculostomy. This represents, to our knowledge, the best indication for intraventricular endoscopy in ICH. However, the indication is rare, and the surgery is technically demanding. Thus, application of the endoscope in intraventricular hemorrhage remains a rare indication. Most neurosurgeons apply the endoscope to suck out blood clots and to clean the ventricular system of an intraventricular hemorrhage. This technique is under continuous discussion, but studies analyzing the surgical technique and the patients' outcome are rare.

The present study from Taiwan, published in this issue, further enhances our knowledge of endoscopic applications in IVH. [5] Of course a data collection of 13 patients has a significant limitation, and no definite conclusions can be drawn from such a small heterogeneous sample. However, the idea of removal of as much blood as possible, to reduce secondary complications makes sense and has a sound theoretical background. Also detailed data are provided to underscore the effect of endoscopic blood clot removal, in this case sample. We believe that further refinement of the technique is necessary, to make it readily applicable for a larger number of neurosurgical centers. In the future, as soon as there are a significant number of neurosurgeons involved, a randomized, multi-center study to evaluate the effect of endoscopic blood clot removal should be undertaken, to come to a more definite conclusion on the value of this technique, for the neurosurgical readership of Neurology India.